Provider Demographics
NPI:1477053825
Name:MATTERN, KATY ANN (LABA)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:ANN
Last Name:MATTERN
Suffix:
Gender:F
Credentials:LABA
Other - Prefix:MISS
Other - First Name:KATY
Other - Middle Name:
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4921 S WENAS RD
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9000
Mailing Address - Country:US
Mailing Address - Phone:509-951-5022
Mailing Address - Fax:
Practice Address - Street 1:4921 S WENAS RD
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-9000
Practice Address - Country:US
Practice Address - Phone:509-951-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAB60829120103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst